Tuesday, May 26, 2009

Recently I was interviewed by Esperanza Magazine about my experience of living with depression here is the article just published

The Mask of Male Depression

For a long time, Chuck P. didn’t know what was wrong with him. A former customer service representative at Wal-Mart in Bowling Green, Kentucky, he sometimes lashed out at coworkers and shoppers. Eventually, he attended anger management classes only to learn that his problem wasn’t anger at all. His therapist helped him identify that he was depressed—and that his irritability was a product of a biochemically-based brain disorder.

“It took me awhile to accept that I was depressed,” says Chuck, 49. “Being a guy, people think that you need to man up and not talk about it. They accuse you of whining about the little things. They don’t understand that depression for guys is difficult because we have all these expectations thrust upon us.”

More than 14 million American adults suffered a major depressive episode in the past year; more than 35 million have had one at some point in their lives. Nearly two-thirds of both those groups are women. However, a chorus of mental health professionals believes that men may suffer from depression at a much higher rate than is documented because they don’t recognize their symptoms or aren’t willing to get help. Even so, more than 6 million men are known to have depression each year in the United States alone, according to the National Institute of Mental Health (NIMH).

In Canada, about 8 percent of adults will experience an episode of major depression and anxiety at some point in their lives and about 5 percent in a given year, reports Health Canada and Statistics Canada. Again, women account for more of those cases, but many mental health leaders say that male depression is underreported.

Part of the reason for this is that men who are depressed often fail to recognize their condition, chalking it up to apathy, low self-esteem, and anger. And as such, experts say, they experience depression differently than women, often masking the disorder by self-medicating with drugs or alcohol. In both countries, men are four times as likely to die by suicide.

“Men tend to feel that they need to rely only on themselves and that it is somehow weak to have to depend on someone else, even for a short time,” says Frederick E. Rabinowitz, PhD, coauthor of Men and Depression: Clinical and Empirical Perspectives (Academic Press, 2000), written to help therapists work with men experiencing depression.

The way that men think about themselves can impede how they are identified and treated for depression, experts say. Compared with women, men tend to be far more concerned with being competitive, powerful, and successful. They often don’t like to admit that they feel fragile or vulnerable, so they’re less likely to talk about their feelings with their friends, loved ones, or even their doctors.

For Chuck, like many men, coming to terms with depression carries deep social and psychological challenges.

“With me, the more I talk about it the more I feel weird,” he says. “If you’re really a man, you’re not supposed to feel this way.” In our society, he adds, “it’s still a problem for most guys to get up the nerve to seek the help or assistance they need to work through this stuff without feeling like it’s going to come back at them in some sort of way. I feel damned if I do and damned if I don’t.”

Jim Blaha, 71, has lived with depression for the past 50 years. At 22, he had a breakdown that landed him in a psychiatric hospital for six weeks. Then, doctors called it “acute depression.” Since that time, he has had a major episode every eight to 10 years.

“When I was first diagnosed—and still today—depression in men simply wasn’t talked about,” says the former accountant and Westinghouse executive, who splits his time between Illinois and Florida. “It was something almost like what the gay community went through: “Don’t ask, don’t tell.”

Even though Blaha’s employer knew about his hospitalizations, “Most people didn’t know what happened to me, so it was never talked about much,” he says. “I kept it under the blanket.”

That’s starting to change. Education on the topic has made Blaha feel more comfortable sharing his story publicly. “Now, I take every opportunity to talk about this. That’s how you start to feel better—talking about it.”

He’s not alone. Scientists and public health officials in North America are now shifting their attention to bringing male depression into the spotlight. Several years ago the NIMH launched a nationwide television, print, and Internet campaign called “Real Men. Real Depression,” designed to counteract the notion that mood disorders are a sign of psychological or moral weakness.

In Canada, the Global Business and Economic Roundtable on Addiction and Mental Health has focused on helping employers recognize the signs of depression in men, both to encourage them to get treatment and improve productivity. And researchers at the NIMH and elsewhere are studying the hormonal and genetic roots of depression as doctors get better at letting their male patients know that there are treatments—both psychological and pharmacological—that work.

Bill Wilkerson helped found the Canadian roundtable. Now in its 10th year, it was inspired by the findings of the Harvard School of Public Health’s 1996 landmark study “Global Burden of Disease,” which found that psychiatric illness, primarily depression, was the leading source of disability.

“You could look at whatever category of occupation—whether it’s judges, lawyers, physicians, plant workers, or office executives—and you can see the tendency to withdraw,” says Wilkerson. “This will reach a point where they hit a wall or the wall hits them.”

Wilkerson says this is why it’s imperative that employers take an active role in helping men who appear to be suffering from depression and anxiety.

“Men, unlike women, are less likely to reach out and be receptive to the suggestion that they may need some kind of support. Culturally, men are in a position where they have lived a life where any kind of suggestion of ill health is an assault to their own self-image. I think men are still coming out from behind those longstanding barriers to recognizing their vulnerability to these issues.”

Dave Schultz, 53, of Winnipeg, Manitoba, believes his depression started when he was a teenager. But the for-mer architectural draftsman said his own negative self-talk prevented him seeking help until 2000.

“I was very critical of myself,” says Schultz, adding that he started medication and talk therapy only after he began to fear he might end his own life.

“I’d just blame it on my character. I thought I was lazy, not worthwhile, not fun to be around, and that it was all my fault. Men, in general, are very reluctant to cry and express deeper feelings. I was no different.

“Simply put, I viewed it as a weakness, not an illness. And for years, I had no idea what was wrong with me.”

An established body of evidence from neuroscience, genetics, and clinical trials shows that depressive illnesses are brain disorders. But just what causes them is still being studied.

Modern brain imaging technologies show that in depression, neural circuits responsible for the regulation of moods, thinking, sleep, appetite, and behavior fail to function properly and critical neurotransmitters—chemicals that brain cells use to communicate—are out of balance.

In some families, depressive disorders seem to occur generation after generation. But they can also occur in people with no family history. Research shows that risk for depression results from the influence of multiple genes acting together with environmental or other non-genetic factors.

Therapists have identified social factors as the leading reason why men have long been left in the dark when it comes to being identified and treated for depression.

Rabinowitz, a professor of psychology at the University of Redlands in California, says men often experience depression differently from women.

“Culturally, women have more words to describe their inner emotional world and men have fewer words to describe it,” says Rabinowitz, who leads depression support groups for men. “So, for guys there’s more of a tendency to try to distract themselves from the nagging from that emotional world.”

They may be grumpy or irritable, or lose their sense of humor. They might drink too much or abuse drugs. They might work all the time or compulsively seek thrills in high-risk behavior. Or, they may become isolated and no longer interested in the people or things they used to enjoy.

Take Schultz, for example. “It was hard for me to derive any sort of joy from any activities in my life,” he says. “I was withdrawn and always took a pessimistic view. I could never feel there was meaning or purpose in life.”

Chuck says his depression has kept him from using his bachelor’s degree, so he works minimum-wage jobs instead. “I don’t want to answer the phone. I don’t want to watch TV. I wake up sometimes and just say, ‘ugh.’ I just stay asleep and try to avoid the whole day.”

Very often, a combination of genetic, cognitive, and environmental factors is involved in the onset of a depressive disorder. Trauma, loss of a loved one, a difficult relationship, a financial problem, or any stressful change in life patterns—whether the change is unwelcome or desired—can trigger a depressive episode in some individuals.

Men are particularly vulnerable when the economy is bad, experts say. Recent studies have shown that up to one in seven men who become unemployed will develop a depressive illness within the following six months. In fact, after relationship difficulties, unemployment is the most likely thing to push a man into a deeper depression. This isn’t surprising, experts say, as work is often the main source of a man’s sense of self-worth and self-esteem.

Whatever the cause of a man’s pain, if he fails to get to the heart of it, he often turns that discomfort outward in the form of aggression, or simply masks it with drugs and alcohol. “Men tend to have a higher substance abuse rate, and the data shows they’re twice as likely to be alcoholics,” Rabinowitz says. “I believe that is a reflection of depression forced outward.”

If a man thinks he may be depressed, the most important thing to do is seek treatment, Rabinowitz adds.

“Men are as successful at doing therapy as women when it’s done with empathy and understanding for the male experience.”

Even when men realize they’redepressed, they often encounter barriers to treating the problem. Talk therapy geared specifically to men is rare and groups like those run by Rabinowitz can be hard to find. While medication can be an effective treatment, it often produces side effects such as weight gain and sexual problems.

Raymond W. Lam, MD, professor and head of the Division of Clinical Neuroscience at the University of British Columbia’s Department of Psychiatry, says that about 30 percent of men taking SSRIs (selective seratonin reuptake inhibitors) will experience sexual side effects, including erectile dysfunction and the inability to achieve an orgasm. He points out, however, that there are non-SSRI antidepressants that do not have sexual side effects.

While at least some of the side effects associated with the SSRIs can be treated with other medications, “it can definitely be a tradeoff,” says Lam, also the medical director of the Mood Disorders Centre of Excellence at UBC Hospital in Vancouver.

Notes William Ashdown, vice president of the Mood Disorders Society of Canada: “Many men feel that a diagnosis of depression is an accusation that they’re impotent. And that feeling over the years has been enhanced by medications that have exactly that effect.”

Steve Poteete-Marshall, 50, a pastor at Walnut United Methodist Church in Walnut, California, has lived with depression and anxiety since he was in his 20s. He says he put off medication treatment because he was fearful of the sexual side effects and “afraid it would ruin my sex life with my wife,” also a church pastor, particularly when they were newlyweds.

Poteete-Marshall dealt with his depression through talk therapy for many years. He finally decided to take antidepressants when, during a stressful church assignment, he began having suicidal thoughts.

“I did get those (sexual) side effects,” Poteete-Marshall says. “And I still have them. But now I try to think of my sexuality as a whole, not just the physical side of it. My wife and I are at a different stage in our relationship, and I can be intimate without it all being just about sex.”

Schultz, who is single, avoided taking medications for the first full year after his initial diagnosis. Ultimately, he discovered that the benefits of feeling better outweighed the side effects.

“The first antidepressant I took caused sexual dysfunction,” he says. “But I was so happy that I was pre-pared to ignore that because I was just so thrilled to get relief from the depression.”

The most important thing to remember, says men who’ve lived with depression, is that it’s possible to manage the disorder with treatment and attention.

“My advice to other men who have depression is to try to be honest—to know the self,” says Blaha. “Don’t be afraid to say, ‘I’m feeling not-so-good right now.’ There’s nothing wrong with having this even if you’re hospitalized with depression. It’s a reality. It’s not a negative. It’s not any different from a broken leg, cancer, or kidney disease. There’s recovery available for it, and there is less and less stigma associated with it.”

Blaha, who has had five hospitalizations for depression during his lifetime, says that getting help has saved his life more than once.

For his part, Schultz left his career as an architectural draftsman in 2006 to help other people who suffer from depression. Today, as a staff member at the Mood Disorders Association of Manitoba, he devotes his career to the cause of helping men get treatment.

“My life has changed dramatically since I got help,” he says. “I still have short periods when I can be overwhelmed by circumstances, but generally I have an optimistic view and have really found that my work helping others has helped me.”

Poteete-Marshall says the key for him was finding the right medication balance despite the side effects.

“You don’t want to be overmedicated so you’re dull and don’t experience the highs of life. It’s taken me several years to get to the place where the side effects are manageable. Now, I can still feel highs and lows, but it’s not the deep highs and lows.”

He also finds healing in raising awareness about the illness.

“I don’t always talk about my depression with my congregation, but I do allow them to know what’s going on. The big thing is, don’t stop exploring it. I talk about how life is a journey all the way. Just because you reach a certain point doesn’t mean you’ll stop learning about yourself or your depression. It will keep challenging you, but see it as that: a challenge, not a deficit.” e

-----Michelle Roberts is a freelance writer based in Portland, Oregon. A recipient of a 2004-05 Rosalynn Carter Fellowship for Mental Health Journalism, she specializes in mental health and family issues.